Perineal Care Checklist for BSN 2nd year midterm PDF

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Summary

Academic notes for nursing students under 2nd year midterm lecture return demonstration...

Description

Perineal Care 

It is a cleansing procedure prescribe for the perineum after various obstetric and gynecologic procedures. Sterile or clean perineal care may be prescribed. It is done also after elimination and as a routine part of hygiene care (bed bath) using clean technique rather than sterile.

A. Learning Objectives Students will: o Perform perineal care correctly. B. Equipment o Bath basin, Waterproof pads o Soap o Toilet tissue o Two or three washcloths o Lotion or ointment o Dry bath towel o Disposable gloves o Bath blanket C. Procedure o

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Evidence to be produced Introduce yourself and identify the patient. Explain procedure and purpose to client. Obtain permission. Close door and pull curtain around bed. Perform hand hygiene and apply gloves. Place waterproof pad under client’s buttocks. Client may be place on a bed pan for perineal care. Females usually assume the dorsal recumbent position. Males may assume the dorsal recumbent or supine position with knees and hips flexed. Expose perineal area. Fold client’s gown up above the genital area. Place a bath blanket over the client using a ”diamond draping technique“ . Corners of bath blanket should point toward the head, sides of body, and between the client’s legs. Fold top

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Rationale Promotes cooperation. Provides privacy.

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Reduce transmission of pathogens

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Waterproof pad prevents wetting of linen. Dorsal recumbent position provides maximal visualization of genital area.

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Draping promotes a sense of privacy and decrease exposure

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linen down to the end of the bed. Tuck sides corners of bath blanket around client’s legs. Lift corner between client’s legs to expose perineal area Moisten and lather washcloths. FEMALE: Clean perineal area in the downward direction (From pubic area to rectum). Clean and dry upper thighs. Use separate quarters of the washcloths as necessary. Clean the labia majora. Separate the labia majora to clean between the labia majora and labia minora. With the labia separated, clean the clitoris, Urethral meatus and vaginal orifice. Rinse the area well with warm water. Pat perineal area dry. Apply lotion to upper thighs. MALE: Gently raise penis. Place a bath blanket under the penis. If the client develops an erection, delay perineal care. Gently grasp the shaft of the penis. If the client is uncircumcised, retract the foreskin (prepuce). Use circular motion to clean the meatus of the penis and glans. Clean the shaft of the penis. Rinse penis. Pat glans and shaft of penis dry. Clean and dry scrotum. Scrotum may need to be lifted during cleaning. Discard soiled washcloths as necessary. Perform anal care. First remove any fecal material with toilet tissue. Clean perineal area by wiping from genitals to anus with one stroke. Discard soiled washcloths as necessary. Clean anus in circular motion. Rinse anal area. Pat dry. Apply lotion. Assist the patient Remove gloves. Wash hands. Remove bath blanket. Place gown down over genitals. Place top linen on client. Document procedure performed, Client’s response and assessments findings

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Cleaning in the directions of the pubic area to rectum reduces risk of transmitting fecal material to the urinary tract. Using clean area of washcloth for each stroke reduces risk of transmitting organisms. Cleaning between the labia removes accumulated smegma. Gentle handling reduces chance of an erection. Smegma accumulates around the foreskin. Replacing of foreskin prevents phimosis. Cleaning moves from area of least to most spoiled  Meatus- circular motion  Glans- outward direction

Cleaning fecal material with toilet tissue removes the bulk of soil prior to washing. Cleaning from genitals to anus reduces chances of transmitting fecal microorganisms to urinary tract. Patting dry reduces skin irritations.  Anus- circular motion Reduces transmission of microorganisms. Covering genitals maintains client’s privacy. Provide evidence of nursing care.

Assessment: Assess for the presence of:     

Irritation, Excoriation, inflammation, swelling Excessive discharge Odor, pain/discomfort Recent rectal/Perineal Surgery Indwelling Catheter

Determine:  Perineal –genital hygiene practices  Self-care abilities...